Connecticut Tech Act Project



[pic]

Application Section 1 of 3: Instructions and Guidelines

Overview

The National Deaf-Blind Equipment Distribution Program (NDBEDP) supports local programs that distribute equipment to low-income individuals who are deaf-blind (have combined hearing and vision loss) to enable access to telephone, advanced communications, and information services. The Connecticut Tech Act Project, Access Through Technology program is Connecticut’s certified entity.

This application is open to CT residents that are deaf-blind and meet the income eligibility guidelines. Its purpose is to request assistive technology devices and services to effectively access telecommunication services, internet access services, and advanced communications, including interexchange services and advanced telecommunications.

Who is eligible to receive equipment?

Individual with low-income who are deaf-blind are eligible to receive equipment provided through the NDBEDP. Applicants must provide verification of their status as low-income and deaf-blind.

Income eligibility

To be eligible, your total family/household income must be below 400% of the Federal Poverty Guidelines, as shown in the following table:

|2020 Federal Poverty Guidelines |

|Number of persons in family/household |400% for everywhere, except Alaska and Hawaii |400% for Alaska |400% for Hawaii |

|1 | $51,040 | $63,800 | $58,720 |

|2 | $68,960 | $86,200 | $79,320 |

|3 | $86,880 | $108,600 | $99,920 |

|4 | $104,800 | $131,000 | $120,520 |

|5 | $122,720 | $153,400 | $141,120 |

|6 | $140,640 | $175,800 | $161,720 |

|7 | $158,560 | $198,200 | $182,320 |

|8 | $176,480 | $220,600 | $202,920 |

|For each additional person, add |$17,920 |$22,400 |$20,600 |

|Source: U.S. Department of Health and Human Services |

For purposes of determining income eligibility for the NDBEDP, the FCC defines “income” and “household” as follows:

“Income” is all income actually received by all members of a household. This includes salary before deductions for taxes, public assistance benefits, social security payments, pensions, unemployment compensation, veteran's benefits, inheritances, alimony, child support payments, worker's compensation benefits, gifts, lottery winnings, and the like. The only exceptions are student financial aid, military housing and cost-of-living allowances, irregular income from occasional small jobs such as baby-sitting or lawn mowing, for example. 

 

A “household” is any individual or group of individuals who are living together at the same address as one economic unit. A household may include related and unrelated persons. An “economic unit” consists of all adult individuals contributing to and sharing in the income and expenses of a household. An adult is any person eighteen years or older. If an adult has no or minimal income, and lives with someone who provides financial support to him/her, both people shall be considered part of the same household. Children under the age of eighteen living with their parents or guardians are considered to be part of the same household as their parents or guardians.

See Section 2 for the family/household income information that must be provided with this application.

Disability eligibility

For this program, the term "deaf-blind" has the same meaning given by the Helen Keller National Center Act. In general, the individual must have a certain vision loss and a hearing loss that, combined, cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working).

Specifically, the FCC’s NDBEDP rule 64.6203(c) states that an individual who is “deaf-blind” is:

(1) Any individual:

(i) Who has a central visual acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both these conditions;

(ii) Who has a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification, or a progressive hearing loss having a prognosis leading to this condition; and

(iii) For whom the combination of impairments described in . . . (i) and (ii) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation.

(2) An applicant's functional abilities with respect to using Telecommunications services, Internet access, and advanced communications services, including interexchange services and information services in various environments shall be considered when determining whether the individual is deaf-blind under . . . (ii) and (iii) of this section.

(3) The definition in this paragraph also includes any individual who, despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional and performance assessment to have severe hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives.

Who can attest to a person’s disability eligibility?

A practicing professional who has direct knowledge of the person's vision and hearing loss, such as:

• Audiologist

• Community-based service provider

• Educator

• Hearing professional

• HKNC representative

• Medical/health professional

• School for the deaf and/or blind

• Specialist in Deaf-Blindness

• Speech pathologist

• State equipment/assistive technology program

• Vision professional

• Vocational rehabilitation counsellor

Such professionals may also include, in the attestation, information about the individual’s functional abilities to use telecommunications, Internet access, and advanced communications services in various settings.

Existing documentation that a person is deaf-blind, such as an individualized education program (IEP) or a statement from a public or private agency such as a Social Security determination letter, may serve as verification of disability. 

See Section 3 for the disability attestation information that must be provided with this application.

Confidentiality policy

CT Tech Act Project is committed to ensuring that your privacy is protected. Information provided on this application form will only be used to determine eligibility for CT Tech Act Project products and services. CT Tech Act Project will not sell, distribute or lease your personal information to third parties unless required by law to do so. The Ct Tech Act Project is committed to ensuring that personal information is secure. In order to prevent unauthorized access or disclosure, suitable physical, electronic and managerial procedures are in place to safeguard and secure the information Ct Tech Act Project collects.

[pic]

Application Section 2 of 3: Applicant’s Personal Data

(Please fill in all fields)

Name of Applicant:      

Date of birth:       Gender:      

(If you are under age 18, your parent or legal guardian must sign the application.)

Street Address:      

City:      State:       Zip Code:      

Primary Phone:       Voice       TTY       VP      

Alternate Phone:       E-mail:      

State in which you are a permanent resident?      

Have you participated in the National Deaf-Blind Equipment Distribution Program before? (check Yes or No) Yes       No      

If yes, what state/states did you participate in the National Deaf-Blind Equipment Distribution Program? (list all):

     

Did you previously receive equipment through National Deaf-Blind Equipment Distribution Program in another state?

(check Yes or No) Yes       No      

If yes, what state/states did you receive equipment through National Deaf-Blind Equipment Distribution Program? (list all):

     

Language preference (check all that apply):

ASL       Close Vision ASL/PSE       Tactile ASL/PSE       English (spoken)       No Formal Language       Pidgin Signed English       Signed English      

Spanish (spoken)       Other –      

Which format do you prefer for written correspondence?

Braille       E-mail       Large Print       Standard Print       Other –      

Contact By:

E-mail       Fax       Text Message       TTY (dial 711 for Relay)      

Video Phone       Phone (voice)      

Alternate Contact (in case of emergency):      

Relationship with Applicant:      

Street Address:      

City:       State:       Zip Code:      

Primary Phone:       E-mail:      

Feedback/Suggestions (optional):      

How did you hear about this program?

      website

      Conference or Seminar

      Disability advocacy group

      Specialist in Deaf-Blind Services

      Education provider /School

      Family Members

      Friends

      Healthcare provider

      Helen Keller National Center (HKNC) representative

      Independent Living Center

      Interpreter

      News / Media (television, magazine, radio)

      Social Media (Facebook, Twitter)

      State Deaf-Blind Project

      Senior Center

      Technology vendor

      Vocational Rehabilitation Counselor

      Other –     

Income eligibility

To confirm your income eligibility, please mail or fax documentation that proves your eligibility for one of the following federal programs:

• Medicaid

• Low income home energy assistance

• Supplemental Security Income (SSI)

• Federal public housing assistance or Section 8

• Food Stamps or Supplement Nutrition Assistance Program (SNAP)

• Temporary Assistance for Needy Families (TANF) or Welfare to Work (WTW)

• National School Lunch Program’s free lunch program

• Veterans and Survivors Pension Benefit

Income (proof of income required, paystubs, tax returns, SSI or SSDI letter)

Gross monthly income (all sources of income) $      

Family size      . If applicant is a minor, include parents in the household and any dependent children, including applicant. If applicant is not a minor, include self, spouse, and any dependent children

If none of the above applies, mail or fax a copy of last year’s Federal IRS 1040 tax form(s) filed by you and members of your family/household, or send other evidence of your family/household income, such as recent Social Security Administration retirement benefit statement(s) or other pension benefit statement(s). Include a signed statement that attests that what you are submitting represents your total family/household income. Note: income eligibility is valid for one year.

I certify that all information provided on this application, including information about my disability and income, is true, complete, and accurate to the best of my knowledge. I authorize program representatives to verify the information provided.

I permit information about me to be shared with my state's current and successor program managers and representatives for the administration of the program and for the delivery of equipment and services to me. I also permit information about me to be reported to the Federal Communications Commission for the administration, operation, and oversight of the program.

If I am accepted into the program, I agree to use program services solely for the purposes intended. I understand that I may not sell, give, or lend to another person any equipment provided to me by the program.

If I provide any false records or fail to comply with these or other requirements or conditions of the program, program officials may end services to me immediately. Also, if I violate these or other requirements or conditions of the program on purpose, program officials may take legal action against me.

I certify that I have read, understand, and accept these conditions to participate in CT Tech Act Project (the National Deaf-Blind Equipment Distribution Program).

I authorize Access to Technology (CT Tech Act Project) and BESB (Bureau of Education and Services for the Blind) to discuss my application.

Print name of applicant or parent/guardian (if applicant is under age 18):

     

Signature: _________________________________ Date: _____________________

Application Section 3 of 3: Disability Verification

This disability verification section is to be completed by a practicing professional who has direct knowledge of the applicant's vision and hearing loss.

Please complete the following fields, and sign and date at the bottom.

Name and Address of Deaf-Blind Individual:

Name of Applicant:      

Street Address:       City/State/Zip:      

Attester Information:

Name of Attester:       Title:      

Agency/Employer:      

E-mail:       Phone:      

Street Address:       City/State/Zip:      

For this program, the term "deaf-blind" has the same meaning given by the Helen Keller National Center Act. In general, the individual must have a certain vision loss and a hearing loss that, combined, cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working).

Specifically, the FCC’s NDBEDP rule 64.6203(c) states that an individual who is “deaf-blind” is:

(1) Any individual:

(i) Who has a central visual acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both these conditions;

(ii) Who has a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification, or a progressive hearing loss having a prognosis leading to this condition; and

(iii) For whom the combination of impairments described in . . . (i) and (ii) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation.

(2) An applicant's functional abilities with respect to using Telecommunications services, Internet access, and advanced communications services in various environments shall be considered when determining whether the individual is deaf-blind under . . . (ii) and (iii) of this section.

(3) The definition in this paragraph also includes any individual who, despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional and performance assessment to have severe hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives.

1. Does this applicant have a visual acuity of 20/200 or less in the better eye with corrective lenses?

YES NO If “yes”, what is it      

Do you have a reasonable expectation that this applicant will progressively reach a visual acuity loss of 2/200?

YES NO

Does this applicant have a visual acuity or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees?

YES NO If “yes”, what is it      

Do you have a reasonable expectation that this applicant has a prognosis that will lead to this condition?

YES NO

2. Does this applicant have a chronic hearing impairment, that most speech is not understood with optimum amplification?

YES NO

Do you have a reasonable expectation that this applicants hearing will progress to the point that speech is not understood with optimum amplification?

YES NO

3. Does the combination of conditions listed in 1&2 cause difficulty with independence in daily living, psychosocial adjustment, or obtaining a vocation?

YES NO

I certify under penalty of perjury that, to the best of my knowledge, this individual is deaf-blind as defined by the FCC as above (and as previously referenced in Section 1)

My Attestation is based on the following:

     

Attester Print:       Date:      

Attester Signature:______________________

Mail, e-mail, or fax completed application (Sections 1, 2 and 3) to:

Access through Technology

55 Farmington Avenue 12th floor

Hartford, CT 06105

ATTN: Muriel C.M. Aparo

E-mail: muriel.aparo@ • Phone: 860-424-5619 •

Fax: 860-424-4850

In compliance with the Americans with Disabilities Act, this information is available in alternate formats upon request.

Privacy Statement

The Federal Communications Commission (FCC) collects personal information about individuals through the National Deaf-Blind Equipment Distribution Program (NDBEDP), a program also known as iCanConnect.  The FCC will use this information to administer and manage the NDBEDP. 

Personal information is provided voluntarily by individuals who request equipment (NDBEDP applicants) and individuals who attest to the disability of NDBEDP applicants.  This information is needed to determine whether an applicant is eligible to participate in the NDBEDP.  In addition, personal information is provided voluntarily by individuals who file NDBEDP-related complaints with the FCC on behalf of themselves or others.  When this information is not provided, it may be impossible to resolve the complaints.  Finally, each state’s NDBEDP-certified equipment distribution program must submit to the FCC certain personal information that it obtained through its NDBEDP activities.  This information is required to maintain each state’s certification to participate in this program.

The FCC is authorized to collect the personal information that is requested through the NDBEDP under sections 1, 4, and 719 of the Communications Act of 1934, as amended; 47 U.S.C. 151, 154, and 620.

The FCC may disclose the information collected through the NDBEDP as permitted under the Privacy Act and as described in the FCC’s Privacy Act System of Records Notice at 77 FR 2721 (Jan. 19, 2012), FCC/CGB-3, “National Deaf-Blind Equipment Distribution Program (NDBEDP),” .

This statement is required by the Privacy Act of 1974, Public Law 93-579, 5 U.S.C. 552a(e)(3).

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download